Healthcare Provider Details

I. General information

NPI: 1003259656
Provider Name (Legal Business Name): JUSTYNA TERESA WADOLOWSKI D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2013
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 5268 BOX 5268
APO AP
96368-5268
US

IV. Provider business mailing address

UNIT 5268 BOX 5268
APO AP
96368-5268
US

V. Phone/Fax

Practice location:
  • Phone: 315-630-4542
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDOS-1692
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberDOS-1692
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: